Medical Malpractice Insights: Consultants – Who called whom and when?

Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

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Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Consultants: Who called whom and when?

When the “slip” slips through the cracks

Facts: An 11-year-old feels pain in her hip while doing a flip turn during swim practice. When the pain persists for a week, she sees her PCP. He diagnoses a groin strain and recommends rest. A week later she is seen in follow-up by a different physician, improving but still in pain. A month later she feels a sudden “pop” in her hip while climbing stairs. She falls and is taken to the ED. The ED physician suspects an acute slipped capital femoral epiphysis (SCFE), and an x-ray proves her correct. She contacts an orthopedist who recommends follow-up in 2-3 days. The name of the surgeon is not recorded. Surgery is not done until 4 days later. By then, avascular necrosis has developed, and she requires a total hip replacement. A lawsuit is filed against both primary care docs, the ED physician, and two orthopedic surgeons.

Plaintiff: Both of the first two docs missed my diagnosis. They didn’t include SCFE in their differential. An x-ray of my hip should have been done. When the ED physician did make the diagnosis, she didn’t follow guidelines for proper treatment. She also followed erroneous recommendations from the on-call orthopedic surgeon and doesn’t have any record of which surgeon she discussed my case with. I should have been admitted and had surgery within 24 hours or less. In fact, 88% of pediatric orthopedic surgeons advise surgery within 8 hours or less (see Reference below). Now I have to live with an artificial hip for the rest of my life.

Defense: Both PCP’s claim there is no certainty that an x-ray would have shown a problem. This was a strain. You can’t even prove when the epiphysis slipped; it might have been a month ago. The ED physician says she made the diagnosis and discussed the case with orthopedist A. Orthopedist A says “It couldn’t have been me. I was on vacation.” ED phone records show orthopedist B was called, but he testifies “There’s no way I was called because I know the standard of care, and if I was called, I would have done immediate surgery.”

Result: After multiple depositions and delays over 5+ years, the parties agreed to a large but confidential pre-trial settlement. Because of the non-disclosure clause in the settlement, information about the relative negligence assessed against each defendant is not available, but one can assume the ED doc took the hardest hit.

Takeaways:

• Physicians must document consultant interactions with name, date, time, and treatment plan. Share the agreed upon plan with the patient in writing.
• An ED physician should be familiar with orthopedic conditions requiring emergency surgery, acute SCFE being one.
• If a referring physician disagrees with an on-call consultant’s telephone recommendation in an urgent situation, get a second opinion or escalate the conversation until agreement is reached.
• SCFE classically presents in an overweight adolescent with non-radiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of trauma. It can be acute or chronic, and if acute, the standard of care is immediate operative stabilization (see Reference below.)

Reference:

Management of Unstable/Acute Slipped Capital Femoral Epiphysis. Mooney JF et al., J Pediatr Orthop, 25:2, 2005

“Plaintiff attorneys are only exposing our medical culture for what it is – overly reliant on fallible humans. Aviation has learned that the best approach to plaintiff lawyers is to starve them. Redesign our processes and change our culture so these mistakes don’t happen.”

John Brookman, retired airline pilot and safety officer